2005 OPEN FORUM Abstracts
RESULTS: TRIAL USE OF VOLUMETRIC CAPNOGRAPHY IN MANAGEMENT OF MECHANICALLY VENTILATED PATIENTS.
John W Farnham, RRT; Sharon K Foust, RRT. Respiratory Care Services, University of Tennessee Medical Center, Knoxville, TN 37920.
Background: Objectively measurable data than can reliably be used to more precisely manage patients receiving mechanical ventilation is a constant quest. Our institution having had the opportunity to measure the results of new ventilator management protocols, we also investigated the clinical applicability of new monitoring equipment with the potential to add quality and improve outcomes for mechanically ventilated patients. We undertook a six-week trial of technology having the capability of monitoring numerous aspects of mechanical ventilation, including volumetric capnography.
Method: The NICO Monitor® (Respironics, Inc., Wallingford, CT) has the capability to noninvasively monitor not only lung mechanics, but also essential cardiac and respiratory interaction. We employed a trial period of six weeks involving all of the adult critical care units. Our process included education of all the therapists working in the affected units, and the use of two protocol therapists as resource persons. The noninvasive monitoring functions utilized included the fixed orifice pneumotach and pressure sensor in combination with the infrared CO2 analysis capabilities. The measured and calculated parameters available from those devices were: volumetric and End Tidal CO2 (VCO2 & ETCO2), alveolar tidal volume (VTalv), alveolar minute ventilation (MValv), and, with entry of PaCO2 the dead space to tidal volume ratio (VD/VT) can be obtained. The device can also distinguish between parameters generated by spontaneous breath versus mechanical. We monitored a total of 28 patients during our trial period.
Results: We had previously determined that in our institution a decrease of 1 day in ventilator length of stay (VLOS) was equivalent to a decrease in hospital length of stay (HLOS) of 0.87 day, and that dollar savings in variable costs (not salary, etc.) were $300/day of HLOS decrease. Financially the results for this cohort of patients were a realized savings of $15,915.00. Clinically the results were varied. 15 (54% of cohort) patients were saved a minimum of 1 day VLOS. 5 tracheostomies were prevented. Other patients were saved VLOS and HLOS that was indeterminable because the system enabled the therapists to prevent liberation failures due to impending exhaustion. 2 patients had been thought to be failing SBT, were shown not to be, and were successfully liberated without further delay.
Conclusions: We determined that the most appropriate way to use the technology was to select specific types of patients rather than blanket use on all patients. The NICO was used during our test period to assess work and effectiveness of ventilation, to assess PEEP levels, to address ventilator dissynchrony, to differentiate and assess treatment of ventilation/perfusion anomalies. This monitor was of particular utility on ALI/ARDS patients and those with complex liberation issues. We observed enough quantifiable and objective capabilities in the short time we were using the NICO to conclude it was an enhancement to the quality of care we gave mechanically ventilated patients. Given that our six weeks with the technology included time spent in educating the entire department, physicians and therapists alike were convinced our results would have been more notable had we had a similar time to evaluate the system after having climbed the learning curve. Further study and testing of this technology is warranted to determine its full capabilities, based on our short-term positive results. Our experience was that it should significantly enhance our abilities to care for complex mechanically ventilated patients.